Back again! - Discharge from Psych Unit

[DorsetCamping]

Some people might recall my multiple threads regarding DM.

Long story short, multiple health conditions, in and out of hospital through lockdown, home carers, respite care and finally a mental breakdown resulting in being admitted to a local psych unit where she has been since July.

Finally the delirium seems to be lifting and her capacity is returning; discharge planning is being discussed. As she only had a DoL order put in place rather than a Section 3, she will be free to go at some point in the near future. I am absolutely terrified about what will happen next. DM can remember very little about what has happened over the last 6 months and thinks her being away is one big conspiracy to finish her off. She remembers nothing of the multiple emergencies, falls, inadequate care provision and is adamant that she wants to return home. She is refusing to entertain going back to the care home she went to for respite because she couldn't come out of her room (just doesn't get the self isolation rules despite me telling her multiple times it was a short-term necessary quarantine).

I don't know what to do or propose at the discharge planning meeting. I would love nothing more than for her to go to her own home but there is no way she could cope mentally or physically. She is incredibly frail on all levels and even with the 4 x daily care visits reinstated wouldn't last long. I would go mad myself through worry.

Does anyone have any experience of next steps following discharge from a psychiatric unit?. It is so hard listening to her plead with me to be allowed home but she has to be safe as well as happy.

Hi Dorset! I was only thinking about you yesterday and wondering how it was going. As you know, my mum was in the MH ward for 11 weeks and she remembers very little of it. Doesn't think there is anything wrong etc etc. SS and the MH team insisted she went into respite for 2 weeks minimum (turned out to be 3) so she could be assessed as to what care package she would need at home. 4 visits have been set up and like you I was thinking the worst and thinking we would have to upgrade to 24 hour care especially at first. She surprised us all though and has settled very well at home considering. She is not keen on the carers coming in but I've told her it is non negotiable. She is frail but no real medical conditions though so a little different from your situation.

You may have to sell it to your mum that this is the only way home, via respite. I found a home where she wasn't confined to her room, just to one section of the home. She could still socially distance mingle with the other quarantined residents which was fine for her. Are they saying she has capacity now?

I don't know what to do or propose at the discharge planning meeting.

I do.

Show them your post and thread 1.

Thanks both. I sometimes have to read back through my threads to remind myself about how bad the last 6 months have been. It's easy to blank out the detail when time marches on and you start to forget the catalogue of drama and incidents.

I visited DM yesterday, optimistic and hopeful that I could sell respite at the most recent nursing home to her, with the spin that it may only be temporary (unlikely). Disappointingly she was having none of it and was yet again similar to dealing with a truculent toddler. Tears, tantrum the lot... she refuses to remember/accept just how bad things were and says she could manage quite well with carers popping in as they did before. Doesn't recall how ill she was or what a worry it was. There's no denying physically she is much improved but still needs help with her mobility and getting to the toilet at night at the very least.
Short of getting a live in carer I don't see how going home can be an option although her psychiatrist is quite clear they if capacity has returned it must be DM's decision. Aaaargh....!

To make matters worse whilst I know we should be grateful that the proposed nursing home still offers Covid funded beds I don't actually think much of the manager who I've had several dealings with. When I tried to discuss the plan with her today and DM's concerns about self-isolating she became quite cold and defensive. Can't put my finger on it but certainly didn't seem thrilled that DM might return and kept saying she hoped DM wouldn't upset the other residents with any kind of relapse . The conversation all seemed very transactional and Covid funding or not I'm not sure it would do DM any good to go back there.

Just don't know what to do for the best

Capacity hasn't returned, though, has it.

Her psychiatrist says capacity has returned, they are just giving it another week or so to ensure consistency

I was amazed when it was deemed to my mum’s capacity had returned but they were right, it has.

I had a similar situation when expressing my concerns about isolation at one CH I contacted. It almost seems like they didn’t want my mum there. After speaking to another home where DM eventually ended up, they were much more positive so I would recommend trying somewhere else. Each home does vary in the way they handle the isolation.

I looked into nighttime care as I was worried mum wouldn’t cope but it is restrictively expensive. Mum is actually fine at night now she’s back at home but I know she doesn’t have the same physical issues your mum does. Does she tend to get up in the night regularly? I’m sorry your DM won’t except going into respite care, as I said previously, the social worker and consultant pretty much insisted on it which made it easier for me and mum had to cutting mate agree. Have you spoken to your social worker about your concerns?

Sorry some strange autocorrects there!! Mum grudgingly agreed to respite care

The bar for mental capacity is so low even the Supreme Court admits it doesn't work. As it stands kittens can pass it.

OP, let the people who say DM has capacity deal with her as to where she goes next. You haven't a choice in this. Back off - it's the only thing that can help her.

I agree with @Supersimkin2 - be really clear with social services “I believe if she goes home this will fail - I am not going to deal with the fallout if it does.”

(You can try saying the same thing to your DM, but I suspect it’s not worth it!)

Another unsuccessful visit. The unit wants her out ASAP and she is adamant that if she can't live with me she is going home

I am done. I will tell the hospital she is now social services problem and I'm having nothing more to do with it. I have my own family issues and her selfishness is staggering. Guaranteed 100% even with SS carers going in she will be back in hospital within days.

Apologies name change fail!

dorset yep there comes a point when you do have to prioritise your immediate crew... it just becomes clear

Be done. Stay done. It's the only way she'll get the help she needs. Good luck, love, to you both.

They need to have a discharge CPA planning meeting, she is under DOLs which means she was assessed as lacking capacity. I'd ask to see her capacity assessment if they believe it is returning because otherwise it's best interest planning. Insist a social worker is allocated and attends CPA meeting. Ring the ward and ask if they have referred to social services

You are not in this alone. Even if mum refuses everything and is assessed as having capacity to do so, you'll have got social services involved a file for her and have opportunity to share your concerns, so it then becomes a quick telephone call to out of hours or social services if/when she doesn't manage at home again. CPNs in community health teams and community Social workers have a number of cases on the caseloads of people with mental health needs , who may have variable capacity, high risk of self neglect or acopia at home due to unwise decisions and there is no easy answer other than multi agency working with client and family

and her selfishness is staggering Try not to blame her. She's facing the loss of any autonomy over her life, other people deciding what she eats, what she wears, not being able to get out of bed in the middle of the night if she can't sleep ... It's not surprising if this worry is all consuming and she doesn't have space to think of other people.

Hi Dorset I was just thinking about you and came on here to see if I could find you. My mum is currently in rehabilitation and suffering from delerium.I have no experience of this at all, mums 89. They want to send her home next week and I know she won’t cope from taking on the phone, haven’t been able to see her as she has been exposed to covid.
Could you put a link up so I could read your other thread again Please. I hope you can get the help you need for your mum and both of you can have peace. I’m sorry I can’t give advice as I haven’t a clue what I’m doing it’s all a nightmare at the moment. Thank you.

Urrgh, just watching news and waiting for inevitable lockdown announcement.

DM is STILL in the unit despite being medically fit. She wants to go home but I'm about 90% convinced she wouldn't cope even with carers.
Still refusing to go back to original nursing home and still no other option available any where else. Still stalemate

Looks like She's going to be locked in that unit for at least another month and nothing I can do. Probably won't even be able to visit.

@DorsetCamping

Urrgh, just watching news and waiting for inevitable lockdown announcement.

DM is STILL in the unit despite being medically fit. She wants to go home but I'm about 90% convinced she wouldn't cope even with carers.
Still refusing to go back to original nursing home and still no other option available any where else. Still stalemate

Looks like She's going to be locked in that unit for at least another month and nothing I can do. Probably won't even be able to visit.

@DorsetCamping sorry to hear nothing has been resolved. Just to let you know that I was able to visit my DM at the MH unit throughout the last lockdown (off the ward) so hopefully it will be the same for you.

What does the SW say about this? What do the ward staff think, do they think she could cope at home? If she goes to a CH at the moment then I think it's unlikely you would be able to visit so maybe she is best off staying put for now.

Fingers crossed I can continue to visit then @flygirl767

How is your DM doing now? Coping well with being at home?

I am constantly replaying every scenario in my head. Both her and I desperately want the discharge to happen; I can only imagine it must be like prison for her now.
However I honestly think that her going home is just kicking the can down the road and we would very soon be back to square one. I still don't have POA or even live particularly close. Even with a care package her support would be very limited and My life would very quickly become consumed again by emergencies/medical/admin/household management tasks and I just can't take that on again.

Ultimately of course it is her decision and she could just demand to go home but thankfully at the moment she understands the issues.
It could all be solved by agreeing to go back to the original NH but she's still resolute in refusing.

Does she have a diagnosis eg dementia (permanent) or was it all delirium (resolvable)?
Have they rechecked her cognitive tests recently?

If she doesn't have dementia then it's hard to suggest she doesn't have capacity (you have to have a disorder of your mind or brain as base 1). However if she is still on the DOLS then that implies she lacks capacity as otherwise she would be taken off and asked to consent to her admission. They can't have it both ways.

If she has capacity then yes she has a right to go home as much as anyone else even if it is an 'unwise decision'. Even if she lacks capacity then her wishes and feelings will be taken into account and would not be disregarded unless it was clearly
very unsafe. You have a right to a say too but it's not your final decision unless you have a registered health and welfare LPA.

If she really has got better then it doesn't necessarily mean the situation would be the same at home as before admission. Like PPs mother it might be better now she had been treated. Maybe she deserves chance to have a last try. If social services (the LA) are funding her care then I am afraid they will explore cheapest options first.

Care homes are reluctant to take people from psych hospitals at the best of times as they see them as trouble. If they might refuse to isolate then many places will refuse them because they cannot risk spread. We get a negative test before discharge but they still have to do 14 days isolation.

None of this means you have to be beholden to doing anything. Please do be honest and only offer the level of support you can sustain. If you can't support shopping, medical appts etc then don't offer to do so. People with no family do manage as they get care packages put in place to deal with it.

We were still discharging people through the last lockdown so don't assume she won't be discharged on the next month. We have to do that as people still need admitting and we'd have no beds if no-one could leave.

You should be invited to a discharge planning meeting. We have family attend via Skype or telephone if F2F not possible. Best of luck I hope it works out.

Ask about mental health follow up too. She should get a care co-ordinator usually a mental health nurse who would be first point of contact if things go wrong that is a safety net she didn't have last time

@DougRossIsTheBoss

Does she have a diagnosis eg dementia (permanent) or was it all delirium (resolvable)? Have they rechecked her cognitive tests recently?

If she doesn't have dementia then it's hard to suggest she doesn't have capacity (you have to have a disorder of your mind or brain as base 1). However if she is still on the DOLS then that implies she lacks capacity as otherwise she would be taken off and asked to consent to her admission. They can't have it both ways.

If she has capacity then yes she has a right to go home as much as anyone else even if it is an 'unwise decision'. Even if she lacks capacity then her wishes and feelings will be taken into account and would not be disregarded unless it was clearly
very unsafe. You have a right to a say too but it's not your final decision unless you have a registered health and welfare LPA.

If she really has got better then it doesn't necessarily mean the situation would be the same at home as before admission. Like PPs mother it might be better now she had been treated. Maybe she deserves chance to have a last try. If social services (the LA) are funding her care then I am afraid they will explore cheapest options first.

Care homes are reluctant to take people from psych hospitals at the best of times as they see them as trouble. If they might refuse to isolate then many places will refuse them because they cannot risk spread. We get a negative test before discharge but they still have to do 14 days isolation.

None of this means you have to be beholden to doing anything. Please do be honest and only offer the level of support you can sustain. If you can't support shopping, medical appts etc then don't offer to do so. People with no family do manage as they get care packages put in place to deal with it.

We were still discharging people through the last lockdown so don't assume she won't be discharged on the next month. We have to do that as people still need admitting and we'd have no beds if no-one could leave.

You should be invited to a discharge planning meeting. We have family attend via Skype or telephone if F2F not possible. Best of luck I hope it works out.

Thank you, that's really helpful.

No there's no other diagnosis and because 'delirium' is not classified as a mental disorder,
there will be no after care.
I've been categorically told DM can expect to receive one community MH visit and then she's on her own in that respect

She has regained capacity and my understanding is that she is now at the unit under voluntary admission. The ward sister seems to be responsible for her discharge but is a nightmare to get hold of. No mention of any involvement by a SW even though I've asked.

OK well if she has recovered and doesn't have an underlying mental illness I guess MH services won't take her on and she does get to make her own decisions.
(Delirium is a risk factor for later dementia though so I'd push for a memory clinic appt to be arranged in 3-6 months at least).

You'd think they'd be keen to discharge if she is no longer unwell. She will be on a delayed discharge list and they will come under pressure. They must be waiting for a care package or funding agreement for one. There would not necessarily be a social worker. We have a discharge planning nurse instead.
I assume this is L.A. funded and not self funded. They should be liaising with you on what the plans are and what progress is made. Maybe find out which day ward round is done and ask to speak to the consultant as they are ultimately in charge of her care overall.

Has there been a home assessment from an OT? That's something we'd see as important evidence of whether someone can manage and what care and equipment they need.

@DougRossIsTheBoss

OK well if she has recovered and doesn't have an underlying mental illness I guess MH services won't take her on and she does get to make her own decisions. (Delirium is a risk factor for later dementia though so I'd push for a memory clinic appt to be arranged in 3-6 months at least).

You'd think they'd be keen to discharge if she is no longer unwell. She will be on a delayed discharge list and they will come under pressure. They must be waiting for a care package or funding agreement for one. There would not necessarily be a social worker. We have a discharge planning nurse instead.
I assume this is L.A. funded and not self funded. They should be liaising with you on what the plans are and what progress is made. Maybe find out which day ward round is done and ask to speak to the consultant as they are ultimately in charge of her care overall.

Has there been a home assessment from an OT? That's something we'd see as important evidence of whether someone can manage and what care and equipment they need.

She's self funding. Her house would have to sold if she goes into acare home but she has no money for home care

Ok well I'd suggest you ask if an OT home assessment has been done and if they are trying to source an LA funded care package for her at home if she is deemed to have capacity and that is her wish.
Make it clear the limits of what you can do and ask for a follow up memory clinic appt.
Ask her if she will make a H&W and financial LPA given she now has capacity and this will be useful in future.
Maybe ask if you can virtually attend ward round for an update.
It doesn't seem there is much else you can do at this point apart from await developments.
I don't think I would bother anymore trying to talk her into going into care as it doesn't seem she will change her mind. I guess if she has to sell her home to fund it that is very final.